Prehospital Hypertonic Saline Resuscitation of Patients With Hypotension and Severe Traumatic Brain - PowerPoint PPT Presentation

1 / 24
About This Presentation
Title:

Prehospital Hypertonic Saline Resuscitation of Patients With Hypotension and Severe Traumatic Brain

Description:

Prehospital Hypertonic Saline Resuscitation of Patients. With Hypotension and ... Rancho Los Amigos score (range, 1-8) Statistical Analyses. primary outcome measure ... – PowerPoint PPT presentation

Number of Views:83
Avg rating:3.0/5.0
Slides: 25
Provided by: MIS128
Category:

less

Transcript and Presenter's Notes

Title: Prehospital Hypertonic Saline Resuscitation of Patients With Hypotension and Severe Traumatic Brain


1
Prehospital Hypertonic Saline Resuscitation of
Patients With Hypotension and Severe Traumatic
Brain Injury
-- JAMA. 20042911350-1357
2
Introduction
TBI hypotension (2X)
2nd brain injury
ICP Hypoxia Hypotension
IV fluid
Mortality rate 31-49
Hypertonic saline HTS
8000090000 long term morbidity
Severe traumatic brain injury (TBI)
Major trauma, young adults
3
Introduction
  • highest survival rates (randomized 4 trial)
  • HTS alone, 60
  • HTS with dextran 70, 56
  • Ringer's lactate solution alone, 49
  • HTS-dextron (randomized 8 trial)
  • survival from 27 to 38 (adjusted P .048)

4
Introduction
Brain trauma foundation
  • Guidelines for Pre-hospital
  • Management of Traumatic Brain Injury

HTS with or without dextran at the "option" level
decrease secondary brain injury
double-blind, randomized controlled trial
Better neurological outcome ?
5
Methods
  • December 14, 1998 April 9, 2002
  • Melbourne, Australia (4 million persons)
  • Paramedics ( by ATLS guideline)
  • Adult patients with major trauma
  • road ambulance to 1 of 12 hospitals,
  • helicopter and road ambulance to a designated
    regional trauma center.

6
Methods
  • Inclusion criteria
  • coma due to blunt head trauma,
  • GCS lt 9
  • hypotension (SBPlt100 mm Hg).
  • Exclusion criteria
  • penetrating trauma
  • lt 18 y/o
  • Pregnant
  • no iv access
  • serious premorbid disease
  • peripheral edema
  • absent sinus rhythm, or cardiac arrest.

7
Randomization and Study Protocol
  • 7.5 saline (HTS) / Ringer's lactate solution
  • Patients, paramedics, treating physicians, and
    study coordinators were all blinded
  • When a patient met the eligibility criteria, the
    next numbered bag of study fluid was infused
  • 10-mL/kg intravenous colloid or crystalloid or
    repeat dose
  • After hospital admission, patient care was at the
    discretion of the attending physicians and
    generally followed the guidelines of the Brain
    Trauma Foundation.

8
Data Collection and Outcome Assessment
  • Data
  • baseline characteristics
  • admission vital signs
  • laboratory data
  • significant events after admission
  • computed tomography scans were reviewed and
    graded for severity by a single neurosurgeon
    (J.L.)

9
Data Collection and Outcome Assessment
  • Glasgow Outcome Score (GOS)
  • Dead
  • Vegetative
  • lower severe disability
  • upper severe disability
  • lower moderate disability
  • upper moderate disability
  • lower good recovery
  • upper good recovery.

3 ,6m later L.J.M
10
Data Collection and Outcome Assessment
  • Secondary outcomes
  • first ICP and cerebral perfusion pressure (CPP)
  • duration of ICP elevation and of inadequate CPP
  • worst oxygenation expressed as lowest PaO2/Fio2
    ratio
  • duration of inotropic support and mechanical
    ventilation
  • Functional Independence Measure (range, 1-7)
  • Rancho Los Amigos score (range, 1-8)

11
Statistical Analyses
  • primary outcome measure
  • GOSE at 6 months
  • Secondary outcome measures
  • serum sodium and systolic blood pressure at
    hospital admission,
  • initial measurement of ICP,
  • hospital mortality rate,
  • GOSE at 3 months.

12
RESULTS
13
RESULTS
14
RESULTS
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
GOSE at 6 months
19
(No Transcript)
20
(No Transcript)
21
Commends
  • neurological outcomes
  • identical 6 months after injury
  • both study groups received the same prehospital
    volume
  • the ICP was lower when first measured in hospital
    in the patients with HTS than in controls. (P
    .08),
  • perhaps because intracranial hypertension is
    usually not problematic in the first hours after
    TBI

22
Commends
  • Interpretation of ICP and CPP outcomes is limited
    because patients who improved quickly or who died
    quickly were unlikely to have ICP measured

23
strength
  • first randomised prehospital trial of HTS
    resuscitation in hypotensive patients with trauma
    with severe brain injury
  • baseline characteristics were well-balanced
    between groups
  • first prehospital resuscitation fluid trial to
    measure long-term neurological function as the
    primary outcome in patients with TBI.

24
limitation
  • not combine HTS with dextran
  • only 229 patients, 80 power to identify a
    1-grade change in the GOS following HTS
  • study population predominantly (90) included
    patients with multisystem trauma
Write a Comment
User Comments (0)
About PowerShow.com